Ebenezer Park Apartments Application

2700 Park Ave S Minneapolis, MN 55407

Phone: (612) 879-2233 Fax: (612) 879-8111 Applicant Information: Please Print

Full Name:

Current Address:

Phone Number: Sex (optional):

Social Security Number: Date of Birth:

Co-Applicant Full Name:

Social Security Number: Date of Birth:

1. Are you a United States Citizen? Yes No

If no, are you a Non Citizen with eligible alien status Yes No

2. Are you a student? Yes No

How did you hear about Ebenezer Park Apartments?

What is the amount of your current monthly rent?

Please check the type of unit you are applying for:

1 Bedroom Mobility Accessible Deaf Equipped 2 Bedroom

Office Use Only Date/Time/Initial:

_________________

For HUD Statistical Use Only (optional) Race of Head of Household: ____American Indian/Alaska Native ____Asian ____Black/African American ____Native Hawaiian/Other Pacific Islander ____White ____Other Ethnicity of Head of Household: ____Hispanic or Latino ____Non-Hispanic or Latino

[Type text] Updated 12/4/18

Housing Information (please complete at least THREE years)

Current Address:

Move In Date: Move Out Date: Rent Amount:________

Landlord Name: Landlord Phone Number:

Previous Address:

Move In Date: Move Out Date: Rent Amount:________

Landlord Name: Landlord Phone Number:

List any other housing within 5 years on another sheet if necessary

Please answer the following:

___Yes ___No Will anyone else live in the apartment on either a full-time or a part-time basis? Children Partner Other

___Yes ___No Have you or any member of your household been asked to leave a rental property for any of the following reasons?

Fraud Eviction Nonpayment of rent Failure to cooperate with recertification process

Other:

___Yes ___No Have you or any member of your household ever been convicted of a felony or a misdemeanor other than a traffic violation? Reason:

___Yes ___No Are you or any member of your household subject to the state sex offender lifetime registration requirement?

All applicants, please list every state in which you and members of your household have lived:

[Type text]

Updated 12/4/18

Acknowledgement/Signatures

I/We understand the information in this application will be used to determine eligibility for Section 8 housing assistance and that this information will be verified. I/We understand that any false or incomplete information may make me/us ineligible for an apartment.

I/We understand that Ebenezer Park Apartments is a smoke free property and there is no smoking in the building or on the grounds.

I/We understand a copy of the TSP (Tenant Selection Plan) can be requested and provided by Ebenezer Park Staff.

Any applicant, who purposefully falsifies, misrepresents or withholds any information related to program eligibility or submits inaccurate and/or incomplete information on this application or during the interview will be rejected for housing. All questions must be answered.

By signing this document I/We acknowledge that I/we have read and completed each section of this rental application, as applicable, and all information given is true, complete and accurate.

All Household members age 18 or older sign below.

Applicant: Date:

Co-Applicant: Date:

PENALTIES FOR MISUSING THIS CONSENT: title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or employee of HUD, the PHA, or the owner_ may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes sited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA, or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 U.S.C. 208(f), (g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 (f), (g) and (h).

[Type text] Updated 12/4/18

OMB Control # 2502-0581 Exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name:

Mailing Address: Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)

Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent

Assist with Recertification Process Change in lease terms Change in house rules Other: ______________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09)

Page 1 of 3 Revised:12/2015

Certification/Recertification Questionnaire Date ________________ Name:__________________________ Address:_________________________ __________________________ Complete the following information for your household and bring this questionnaire to your Initial Certification interview. A. Household information 1. List all members of the household.

Name (first and last name) Relationship Date of birth Social security number 2. Additional household information Yes No Are you or any member of your household a member of the US Armed Forces or a US Veteran? Are any household members temporarily absent? If yes, list the names: ____________________________________________________________ Are any household members permanently absent? If yes, list the names: ____________________________________________________________ Are there any Foster Children or Foster Adults who are part of the household? If yes, list the names: ____________________________________________________________ Are there any Live-In Care attendants who are part of the household? If yes, list the names: ____________________________________________________________ Are any members of the household enrolled as a student at an Institution of higher education as defined under Section 102 of the Higher Education Act of 1965 (20 U.S.C. 1002)? If yes, list the names: ____________________________________________________________

Has the employment status of any household member(s) changed? If yes, list the member name(s) and the type of change (include the employer’s name): ____________________________________________________________________________

B. Income and Assets Enter the amount received or the asset value for all questions that you answer “Yes”. 1. Do you or any member of your household receive or expect to receive: Yes No Amount

Wages, salaries (includes overtime, tips, bonuses, and self-employment)? Does any member of your household work for someone who pays them cash?

Regular pay as a member of the armed forces?

Any benefits from the county? (MSA, MFIP, Food Stamps, etc) Child support or alimony? Any type of income from Social Security Administration? (RSDI, SSDI, SSI)

Pensions (Railroad, etc.)?

Retirement benefits/funds? Veteran’s Administration benefits? Unemployment benefits or severance pay?

Workman’s compensation?

Annuities or life insurance dividends? Insurance policies (other than rental, auto, or health/medical)? Disability or death benefits?

Name_______________ Apt # __________

1. Do you or any member of your household receive or expect to receive: Yes No Amount Any cash or other assistance (other than HUD) for any utility expenses (telephone, cable/satellite, internet), including a flat rate as part of a low-income assistance program?

Regular cash contributions or gifts from individuals not living in the unit or organizations such as churches (includes rent, utilities, groceries, etc)?

Scholarships, educational grants or work study?

2. Have you received or expect to receive any lump sum payments such as: Yes No Amount Inheritances, Capital gains, or lottery winnings? Insurance settlements for health, accident, Workers Compensation, etc? Social Security benefits, unemployment compensation, etc.? (This is NOT your regular SS or SSI income payment).

Other? (specify) _______________________________________________________

3. Do you have any of the following (including overseas accounts): Yes No Value

Checking accounts? (If yes, enter the balance) Savings accounts? (If yes, enter the balance) Direct Express (or other debit card) account for direct deposit of Social Security/SSI income (not into a checking or savings account)?

Money market funds? Certificates of deposit? Stocks, bonds? Annuities, securities? Trusts?

If yes, is the trust(s) irrevocable? IRA or Keogh accounts or Other retirement accounts? Burial or funeral policies? Cash on hand (in apartment, purse, wallet, etc.) Safety deposit box, at home, etc?

Do you have any coin collections, stamps, jewelry or gems, or any other items held as an investment? (this does not include wedding rings and other personal jewelry)

Do you own a home or other real estate?

If yes, are you in the process of selling it? Do you receive rental income from a home or other real estate? Have you disposed of any assets for less than Fair Market Value in the past two years? (This includes cash donations to charities, religious organizations, family, or friends.) If yes, list the asset(s) you disposed of, the date of disposition, the fair market value and the amount received: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Are any of the assets listed above held jointly with another person? If yes, list the assets: _______________________________________________________________________________ ________________________________________________________________________________________________

Page 2 of 3 Revised:12/2015

Name_______________ Apt # __________

C. Other Information – Enter the amount you pay per year for all questions that you answer Yes. 1. Child and dependent care Yes No Amount Do you pay child care expenses for a child (or children) under age 13 because you

(check one box only) work are actively looking for work attend school?

If yes, enter the provider name(s) and address(es):__________________________________________________________

Is any part of the child care expense paid by another person or agency? If yes, enter the name and address ____________________________________________

Do you pay for a care attendant or any equipment for a disabled household member necessary to enable that person or someone else in the household to work? If yes, enter the provider’s name and address:___________________________________

Is any part of the care attendant expense paid by another person or agency? If yes, enter the name and address:____________________________________________

2. Medical - Complete only if the head of household, spouse or adult co-head is at least 62 years old or disabled. Enter medical expenses for all household members. Yes No Amount Do you have Medicare? If yes, do you pay the premiums for Part B (or have them withheld from your Social Security income)?

Do you receive Medical Assistance? If yes, do you have a spend down or waiver obligation?

Do you have any other kind of medical insurance? If yes, do you pay the premiums? Enter the company name and address: ___________________________________

Do you pay for prescription medication or prescription co-pays? If yes, enter the pharmacy name and location: ___________________________________

Do you pay for any non-prescription (over the counter) medication that your doctor has asked you to use regularly? (such as aspirin, eye drops, laxatives, etc.) If yes, list the medication: ___________________________________________________ Do you have receipts to demonstrate the average expense of these items?

Do you have any old medical bills on which you are paying?

Do you expect to have any extraordinary medical or dental expense in the next 12 months that will not be covered by insurance or Medicare/Medical Assistance? If yes, enter the type of expense: _____________________________________________

I/We certify that I/we have been asked the above statements and they are true and complete to the best of my/our knowledge. I/We understand that it is my/our responsibility to report to management changes in income, assets, expenses and/or family composition whenever they occur. Submittal of false statements is punishable under Federal law. _________________________________________________ _______________ Head of household Date _________________________________________________ _______________ Spouse or Co-head of household Date _________________________________________, _______________ _______________ Signature of person assisting with completion of this form, relationship to tenant Date

Page 3 of 3 Revised:12/2015

701 5th Street South ● Hopkins, MN 55343 PH> 952-545-3953 / 888-389-4023 ● FX> 952-545-3973 / 888-389-4024 ● www.RentalHistoryReports.com

General Consent FormPersonal Information:

I, ______________________________________________________________________________________ have made Last Name First Middle Maiden

application with _________________________________________ for_______________________________________ Company Name State Purpose

_________________________________________________________________________________________________Current Address City State Zip Code

_________________________________________________________________________________________________Previous Address City State Zip Code

____/_____/_____ ______ __________________ ______________________________ (_____)_____________ Date of Birth Sex Social Security Number Driver’s License State Home Phone

Release: I/We authorize Rental History Reports (RHR) and/or the above named company to do a complete investigation of all information provided in my application for residency. I/We have personally filled in and/or reviewed all information contained within the application. I/We understand failure to complete these documents completely and truthfully may result in denial and/or forfeit of deposit. A complete investigation may include any or all of the following: credit report, verification of employment and income, criminal record search, rental history references (including MPHA), unlawful detainer/eviction investigation, identity trace, sex offender search, terrorism search, check writing history and personal interviews with all provided references. The source of the information may come from, but is not limited to: credit bureaus, banks and other depository institutions, current and former employers, federal or state records including state employment security agency records, county or state criminal records, county agencies as it relates to the applicant’s eligibility, non-eligibility and/or benefit amounts received by the tenant, or other sources as required. It is understood that a photocopy or facsimile copy of this form will serve as authorization. I/We understand that I/We have a right to make a written request within 30 days to receive information pertaining to this report if I/We are not accepted based upon information contained in the report. I/We authorize RHR to produce to the credit granter federal and state records of employment and income history, including state employment security agency records. This authorization continues in effect for one (1) year unless limited by state law, in which case, the authorization continues in effect for the maximum period not to exceed one (1) year. Notice to applications applying for a community in Minneapolis and St. Paul only: If you are charged an application fee but a consumer credit report or tenant screen report is not ordered, you are entitled to a refund of the application fee. Please circle your preferred method for return of the application fee as either 1) mail, 2) destroy it, or 3) hold for retrieval upon one business-days’ notice. Any controversy or claim arising out of or relatingto this agreement, or breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its CommercialArbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

Applicant Signature Date

OUT-OF-STATE CRIMINAL RECORDS SEARCH

City / County State City / County State

City / County State City / County State

(FOR OFFICE USE ONLY)

SITE NAME: RHR ACCT #:

Ebenezer Park Apartments

2700 Park Ave S Minneapolis, MN 55407

Phone: (612)879-2233 Fax: (612)879-8111

Effective October 1, 2011, anyone moving into a Housing with Services setting in the state of Minnesota is required to obtain a Verification Code from the Senior Linkage Line. This is required by the State Legislature in order to sign a lease. If you have any questions, please see the enclosed brochure on this topic.

Please call Senior Linkage Line at the number below and request a verification code. Once you have called, please complete this form in full and submit it with your application for housing at Ebenezer Park Apartments.

Senior Linkage Line: 1-800-333-2433

Applicant Name:

Date Called: Time Called:

Who did you speak with:

Verification Code:

Uniform Consumer Information Guide

1. Name of Establishment: EBENEZER PARK APARTMENTS 2. Address, City, State, Zip: 2700 PARK AVE, MINNEAPOLIS, MN - 55407 3. Phone: 612-879-2233 4. Fax: 612-879-8111 5. Web Site: Fairviewebenezer.org 6. Contact Person: Housing Manager, Bill Peterson This information is current as of: December 23, 2016 This Guide was developed to help consumers compare housing, services and costs to help you choose a Housing with Services Establishment that will best meet your needs. The intent is that each individual makes informed choices about where they live and what kind of help they need; and that each individual lives with their maximum independence, dignity, respect and privacy. Housing With Services: In this setting, you are renting “housing” and buying health-related “services.” A single company may provide both the housing and the services, or the building may have an arrangement with home care agencies and other companies to provide some or all of the services. Please note that not all Housing With Services provide Assisted Living. Assisted Living: The legal requirements for Assisted Living vary by state. Minnesota’s laws related to Assisted Living are based on the concept of “Housing With Services.” In Minnesota, Housing With Services providers may call themselves “Assisted Living” only when they meet additional basic requirements under Minnesota law [MN Statute 144G]. The rights you have as a tenant of the housing and a client of the services are listed on the last page of this Guide. While this Guide is designed to help you find the Establishment that best matches your needs, no Guide can cover every detail. Housing With Services Establishments vary in size, services and costs so be sure to visit the places you are considering, and ask to meet with a staff person one-on-one to discuss your specific needs and preferences.

Here are some things to consider during your visit:

• Ask to see a copy of their standard housing contract.

• What is the total amount it will cost to live and receive services at this building per month? Ask for specifics, including whether items are individually priced or packaged together.

• Why could the housing with services ask a tenant to move out?

• What are the limitations on services a client can receive from this provider? What are the reasons why the provider could stop providing services to a client?

• Does the provider offer opportunities for religious or spiritual practice?

• What opportunities and policies exist for tenants/clients and families to make recommendations about the building and services?

Updated 5/2016 Page 1 of 8

You can get further information, at no cost, about care options from:

• Senior LinkAge Line at 1-800-333-2433; www.mnaging.org/advisor/SLL.htm

• County’s Long Term Care Consultation Telephone number:

• Office of Ombudsman for Long Term Care at 1-800-657-3591; www.mnaging.org

• Minnesota Directory to locate community resources: www.MinnesotaHelp.Info

When you move into a building, you will sign a rental or residency agreement that covers your occupancy of an apartment or unit. Review this agreement carefully prior to signing because it will identify situations when the landlord could ask you to move out, such as non-payment, damage to the building, or other reasons. Home Care Provider: In addition to a rental agreement, you will also sign a service agreement or service plan that covers services you will receive from the licensed home care provider. The building owner may be the home care provider and other times services may be provided by one or more outside home care providers. You have the right to choose freely among home care providers and to change providers after services have begun. This building has an arrangement with the following home care agency to provide services to its tenants:

Home Care Provider 1. Name of home care provider: EBENEZER HOME CARE 2. Address, City, State, Zip: 2722 PARK AVENUE SOUTH, MINNEAPOLIS, MN - 55407 3. Phone: 612-874-3460 4. Fax: 612-874-3465 5. Web Site: 6. Contact person: Laura Polifka 7. Department of Health (MDH) home care license:

Comprehensive home care license Basic home care license 8. Medicare Certified: Yes No *Notes regarding MDH home care licenses.

• A Comprehensive home care provider may provide medication administration and therapies such as physical and occupational therapy.

• A Basic home care provider may provide basic home care services. A Basic home care provider

cannot provide health-related services, such as medication administration or therapies such as physical or occupational therapy.

• Only a Medicare-Certified home health agency eligible to receive Medicare payment. All

Medicare-Certified home health agencies must be licensed as a Comprehensive home care provider.

Updated 5/2016 Page 2 of 8

Building Details and Features Total Number of Rental Units: 200 The following table includes information about the minimum amount it will cost you to live here, depending on the type of unit you choose. In addition to rent, the monthly base rate may include some services. Be sure to ask if there are other required fees or charges besides the base rate, such as security deposit, garage fee, charge for a registered nurse assessment or other additional fees.

Size/Type of Unit Square Footage (include range)

Check if Private Bath

Monthly Base Rate (include cost range)

Two-bedroom apartment 645 Sq. ft. $25.00 to $1,063 One-bedroom apartment 545 Sq. ft. $25.00 to $889 Studio/efficiency apartment Sq. ft. $ Private room Sq. ft. $ Semi-private room Sq. ft. $ Other Sq. ft. $ Note: Monthly base rate may include some supportive and/or health-related services. Monthly Base Rate includes the utilities checked below:

Heat Electricity Telephone Cable or Satellite TV Building features include the items checked below (additional fees may apply):

Community dining room Chapel Whirlpool Private entertaining space Exercise room Garage parking Beauty/barber shop Activity room Off street parking Central air conditioning Internet access Guest accommodations Window air conditioners Laundry Room Washer/dryer in unit Other:

This building has the following security features and systems for controlling who enters and exits the building:

Security guard Key card access Other lock system Additional security features: Non-medical Building staff available 24 hours

This building has the following accessibility features:

Elevator Ramps Accessible bathrooms Additional accessibility features: See attached description. Is smoking permitted in tenants’ rooms/apartments?

Yes No Additional deposit required Are pets permitted?

Yes No Additional deposit required Types or sizes of pets are limited: See attached description.

Updated 5/2016 Page 3 of 8

Payment for Rent and Services Rent: This building has or accepts the following forms of payment for rent:

The building offers reduced rents for income-qualified persons or accepts federal rent subsidy

The building accepts Minnesota Group Residential Housing payments for rent and included food costs for qualified, low-income persons

Private pay / Co-pay Long Term Care Insurance

Services: This building’s home care provider is eligible to receive and accepts the following types of payment for health-related services:

Medicare reimbursement for Medicare-eligible services (See http://www.cms.gov/center/PeopleWithMedicareCenter.asp for general Medicare information)

Medical Assistance (Medicaid) reimbursement for eligible services for qualified low-income persons (such as Elderly Waiver or CADI)

Private pay / Co-pay Long Term Care Insurance

General note about public assistance: Be sure to ask about any limits that may apply if the provider accepts public funding for rents or services. If you need assistance in paying for your housing or your services, contact the county to determine if you are eligible for Medical Assistance or Group Residential Housing. For information on subsidized housing, contact Senior LinkAge Line at 1-800-333-2433.

Assisted Living and/or Special Care Unit Assisted Living: Assisted living services are available in this building:

To all tenants of the building To tenants in a designated part of the building, which is: To a limited number of tenants. Our assisted living program can serve tenants.

Minnesota law requires Establishments providing Assisted Living to make available an RN assessment at the time of or prior to move in. Contact to make arrangement for this assessment. Special Care Unit: Does this building offer a specialized care program or special unit for Alzheimer’s disease or related disorders?

Yes No If yes, a copy of the disclosure information required by Minnesota law (MN Statute §325F.72) is attached.

A description of other available specialized services is attached. Updated 5/2016 Page 4 of 8

Staff Availability Staff Availability: Is there someone in this building awake at all times? Yes No

The following is additional information about the building’s response system, such as how clients call for assistance, who responds, and where they are located: Pull cords in each unit to alert non-medical building staff of maintenance, security or medical emergencies only. Non-medical building staff will assist calling 911 for medical emergencies if necessary. In addition, residents have access to a 24 hour building response phone number.

Assisted Living Establishments Only: Minnesota law requires establishments providing assisted living to have someone available 24 hours per day, 7 days per week, who is responsible for responding to client requests for assistance with health or safety needs. If “no” is checked above, the description of the system required by Minnesota law is attached.

Daily Check: Is there a system to check on each client at least daily? Yes No

This building’s system is:

Assisted Living Establishments Only: Minnesota law requires establishments providing assisted living to have a system to check on each client at least daily.

Services Offered

Basic Home Care Providers can provide Supportive Services and Basic Home Care Services. Comprehensive Home Care Providers can provide all services, including Supportive, Basic, and Comprehensive Home Care Services.

Supportive Services Availability Pricing Yes No Days In Base

Rate Additional

Charge Breakfast Lunch Monday - Friday Evening Meal Snacks Meal Delivery Special diets – see below Personal Laundry Laundry Sheets and Towels Housekeeping Assistance with Bills and Finances Activities & Socialization As Scheduled Reasonable Assistance with Arranging Transportation upon Request

Monday - Friday

Updated 5/2016 Page 5 of 8

Supportive Services Transportation Provided Scheduled Outings Reasonable Assistance Accessing Community Resources

Monday - Friday

Note: Assisted Living Establishments must offer all of the following: (1) two meals per day, (2) weekly housekeeping and weekly laundry service, (3) a system for daily checks, and (4) “awake” staff 24/7 to respond to health and safety needs of clients. The following special diets are available: Diabetic Low sodium Other

Basic Home Care Services Availability Pricing

Days

Evenings

Night Included in base rate

Additional

Charge Dressing Self-feeding Oral Hygiene Hair Care Grooming Toileting Bathing Standby Assistance Verbal or Visual Reminders to Take Regularly Scheduled Medication

Treatment and/or Exercise Cues or Reminders

Preparing Modified Diets Ordered by a Licensed Health Professional

Laundry Housekeeping Meal Preparation Shopping Other: Other: Note: Check with provider for how they define times for days, evenings and nights.

Updated 5/2016 Page 6 of 8

Health-Related Services – Comprehensive Home Care Providers Only

Availability Price

Day Evening

Night

Included in base rate

Additional Charge

Registered Nurse Services Licensed Practical Nurse Services Trained Unlicensed Personnel Medication Administration Medication Set-ups by a Nurse Medication Cues and/or Reminders Assistance with Self-Administration of Medications

Insulin Injections Other Injections Wound Care Physical Therapy Services Occupational Therapy Services Speech Therapy Services Respiratory Therapy Services Hands-on Assistance with Transfers and Mobility

Social Worker Services Dietitian/Nutritionist Services Eating Assistance with Complicating Eating Problems

Complex or Specialty Healthcare Services

Oxygen Management Blood Glucose Routine Foot Care Nebulizer Treatments Blood Pressure Checks Overnight Companion or Respite Other: Other:

Note: Check with provider for how they define times for days, evenings and nights.

See attached special notes for health-related services

Updated 5/2016 Page 7 of 8

Your Legal Rights A number of laws exist to protect those who choose Housing with Services Establishments. Here is a partial list of the laws and consumer rights that apply. • Minnesota’s Housing-with-Services Act requires housing with services establishments to

include specific items in their contract. [MN Statute 144D]

• MN Statute 144G requires Assisted Living Establishments to have a minimum set of services available and to meet other legal standards.

• As a building tenant you will have rights under Minnesota’s Landlord-Tenant law. For a summary of this law, you may call the Minnesota Attorney General at 651-296-3353 or 1-800-657-3787. [TTY: 651-297-7206 / 1-800-366-4812] Current tenants may ask their landlord for a summary. [MN Statute 504B]

• The federal Fair Housing Act and the Minnesota Human Rights Act make it illegal for a landlord to discriminate based on race, national origin, sex, disability, and other factors. The federal Americans with Disabilities Act provides additional protections for persons with disabilities. If you believe you have been discriminated against, call the Minnesota Department of Human Rights at 651-539-1100 or 1-800-657-3704. [TTY: 1-800-627-3529]

• Providers that offer a special program or setting for persons with Alzheimer’s disease or related disorders must train staff in dementia care and provide information to consumers about that training. [MN Statute 144D.065]

• The Minnesota Home Care Bill of Rights lists specific rights for people who are served by a licensed home care provider. [MN Statutes 144A.44 to 144A.441]

• Minnesota’s Vulnerable Adult Act lists the legal protections for vulnerable adults regardless of where they live. [MN Statutes 626.557 to 626.5572]

• You may contact the Office of Health Facility Complaints for concerns related to a home care provider at 651-201-4201 or e-mail at health.ohfc-complaints@state.mn.us. Also, the Minnesota Adult Abuse Maltreatment Center (MAARC) is the state-wide common entry point for accepting reports of suspected maltreatment of vulnerable adults. The MAARC toll-free phone number is 844-880-1574 and is available 24/7 to accept reports from the general public.

For more information about your rights under any of these laws, you may call the Office of Ombudsman for Long Term Care at (toll free) 1-800-657-3591, TDD/TTY call 711. The template for this document was developed for use by Housing with Services Establishments as

described in MN Statutes 144D and 144G. This is the end of the standard Uniform Consumer Information Guide. Any additional pages or addendums have been provided by the Housing with

Services Establishment. Updated 5/2016 Page 8 of 8